Pharmacy Services

CenCal Health is committed to providing consistent, compassionate, and local support to all CenCal Health providers and members.

CenCal Health’s Pharmacy Team is comprised of Pharmacist and Pharmacy Technician staff. Our Pharmacy Team is ready to assist our provider network and membership with pharmacy-related inquires and education.

Medi-Cal Rx Update: Pediatric Integration, effective January 31, 2025

Two-Week Countdown: Completion of Pediatric Integration of Members 21 Years of Age and Younger
30-Day Countdown: Completion of Pediatric Integration of Members 21 Years of Age and Younger
Coming Soon: Completion of Pediatric Integration of Members 21 Years of Age and Younger
Now Active – Pediatric Integration for New Start Therapies and CCS Panel Authority
Now Available: CCS Panel Authority Policy Exclusions on the Medi-Cal Rx Approved NDC List
Update: Important Policy Adjustment for Pediatric Integration
30-Day Countdown: Pediatric Integration of Members 21 Years of Age and Younger
Medi-Cal Rx Pediatric Integration - Frequently Asked Questions (FAQs)

Medi-Cal Rx: Medi-Cal Pharmacy Benefit

Effective January 1, 2022, CenCal Health’s Pharmacy benefit called Medi-Cal Rx is administered through DHCS and its vendor, Prime Therapeutics State Government Solutions LLC. Prime provides a comprehensive suite of administrative services as directed by DHCS, which includes claims management/adjudication, prior authorization, utilization management, and customer/support.

Medi-Cal Rx is responsible for administering the following when billed by a pharmacy on a pharmacy claim:

Covered Outpatient Drugs, including Physician-Administered -Drugs (PADs)
Medical Supplies
Enteral Nutritional Products

Additional information regarding Medi-Cal Rx can be found in the “Medi-Cal Rx News” tab below and directly from the DHCS Medi-Cal Rx web site.

For additional assistance contact Medi-Cal Rx Customer Service at: (800) 977-2273

You may also want to visit the Medi-Cal Rx Communication page for any upcoming bulletins and news.

View the DHCS Medi-Cal Rx Website

CenCal Health Pharmacy Services: Medical Pharmacy Management

CenCal Health and the Pharmacy Services Team will be responsible for a variety of activities including, but not limited to: oversight of clinical pharmacy adherence, Drug Utilization Review (DUR) and all utilization management associated with pharmacy services (Physician-Administered-Drug) billed on a medical and institutional claim. CenCal Health defines the utilization management of Physician-Administered-Drugs on the medical benefit as Medical Pharmacy Management.

Additional information and education resources for CenCal Health’s Medical Pharmacy Management Program can be found on our Medical Pharmacy Management page.

Respiratory syncytial virus (RSV) is recognized as one of the most common causes of childhood illness and is the most common cause of hospitalization in infants. It causes annual outbreaks of respiratory illnesses in all age groups, and usually starts in the fall and peaks in the winter in most regions in the United States. The CDC recommends RSV vaccination for all adults ages 75 and older and adults ages60-74 who are at increased risk of severe RSV. To protect infants from severe RSV, CDC recommends an RSV vaccine for pregnant people, or a monoclonal antibody given to the baby after birth.

For adults who need an RSV vaccine and have not yet received a dose, RSV vaccine can be administered at any time during the year, but the best time to vaccinate patients is in late summer and early fall before RSV usually starts to spread in the community. RSV vaccine is not an annual vaccine, meaning patients do not need a dose every RSV season. Studies are ongoing to determine whether (and if so, when) revaccination may be needed. There are three RSV vaccines licensed by the U.S. Food and Drug Administration for use in adults ages 60 and older in the United States and they are Arexvy, mResvia, and Abrysvo.

There are two safe and effective immunizations to prevent RSV lower respiratory tract infection in infants. Either a maternal vaccination (Abrysvo) given to mom during pregnancy, or a monoclonal antibody (Beyfortus) given to the baby is recommended, but administration of both is not needed to protect most infants.

Most RSV vaccines are a Medi-Cal benefit and can be covered through the CenCal Health medical benefit or Medi-Cal Rx pharmacy benefit. The exception is Beyfortus which is a covered under the Vaccines for Children (VFC) program and can only be obtained through VFC providers. Medi-Cal will reimburse VFC enrolled providers for VFC funded vaccines when administered for Medi-Cal members 18 years of age and younger for the following three different services:

Vaccine Administration Fee
Professional Dispensing Fee
Pharmacist Services (consultation and assessment [vaccine initiation] fee)

Please reference the Vaccines For Children Program: Medi-Cal Reference Guide for further information.

If you have questions or need additional information, please contact CenCal Health Pharmacy Department at (805) 562-1080.

Coming Soon: Completion of Pediatric Integration of Members 21 Years of Age and Younger

On January 31, 2025, Medi-Cal Rx initiated implementation of claim utilization management (UM) edits and prior authorization (PA) requirements for new start prescriptions for members 21 years of age and younger, known as Pediatric Integration.

Effective April 25, 2025, Medi-Cal Rx will complete implementation of claim UM edits and PA requirements for all members, including members 21 years of age and younger, for all drugs/products. As a result, claims for continuing therapy prescriptions for pediatric members 21 years of age and younger will be subject to PA requirements.

Pharmacy providers and prescribers should continue to submit proactive PA requests up to 100 days in advance of therapy refill dates or PA expiration for members 1 year of age and older. Currently approved PAs will remain active through their length of authorization.

The Department of Health Care Services (DHCS) has created a Pediatric Integration Q&A document based upon stakeholder feedback received during recent meetings and via email.

Pediatric Integration Information can be found directly on the Medi-Cal Rx, Education & Outreach Page under Pediatric Integration.

For any provider inquiries regarding Medi-Cal Rx, please call the CenCal Health Pharmacy Department at (805) 562-1080.

COVID-19 Antigen Over-the-Counter Test Coverage Updates, Effective October 1, 2024.

Effective October 1, 2024, quantity restrictions for over-the-counter (OTC) self-administered COVID-19 antigen tests, which test for diagnosis of a current infection with SARS-CoV-2 (the virus that causes COVID-19), will be updated to allow for 4 tests per 30-day period per member. Covered Medi-Cal Rx tests are restricted to the List of Contracted COVID-19 Antigen Over-the-Counter Tests, which has been updated to include added tests and can be found on the Forms & Information page of the Medi-Cal Rx Provider Portal. Note that certain tests have been removed from the List. These tests may be covered through December 31, 2024, with an approved prior authorization (PA) request demonstrating medical necessity. On and after January 1, 2025, these deleted tests will no longer be billable through Medi-Cal Rx, even with an approved PA request. Refer to the updated List for product changes.

For additional information regarding COVID-19 Antigen Over-the-Counter Tests, view the COVID-19 Antigen Over-the-Counter Test Coverage Updates, Effective October 1, 2024 PDF.